 |
 |
|
|
This form is completed by individuals who are applying to work in a residential treatment center, independent living preparation program, group care center for minors or a child placement agency. This form is also used by those applying to be licensed as a foster parent or by an adult household member in a family foster home.
The information provided on the form is used to assess the individual for employment or licensure. The form is to be retained in the individual’s personnel or licensing file. For foster homes to be licensed by the Department, a copy of the form is submitted along with DCI and FBI fingerprint cards to the Division of Child Protection Services for processing of criminal record checks.
If you have a question about this form, contact the Family Services Specialist in your local office or call (605) 773-3227 for additional information.